Provider Demographics
NPI:1124502679
Name:BLUE, SOPHIA ANTONIA (LPTA)
Entity type:Individual
Prefix:MISS
First Name:SOPHIA
Middle Name:ANTONIA
Last Name:BLUE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4291 W LINDA DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2617
Mailing Address - Country:US
Mailing Address - Phone:678-576-9652
Mailing Address - Fax:
Practice Address - Street 1:2130 ANDERSON MILL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1806
Practice Address - Country:US
Practice Address - Phone:770-941-8813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001390225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant